Cognitive Behavioral Therapy for Tinnitus

Cognitive Behavioral
Therapy for Tinnitus
Bruce Hubbard, Ph.D.
ATA Professional Member since 2014
“I’m trapped! It won’t stop! It’s on 24-7 and I
can’t think about anything else. I’m desperate
for relief, but convinced relief won’t come.
My life is ruined. I’m certain that I can never
learn to live with tinnitus!”
I am an experienced clinical psychologist who has
worked with countless patients, including many with
severe tinnitus. But the words above are not from one
of my patients. They came from my own lips, nine
years ago, when my life was hijacked by tinnitus.
These panicked, pessimistic sentiments reflect a condition called tinnitus distress—a perfect storm of anger,
annoyance, anxiety, fear, sadness, and despair, that
impairs concentration, interferes with sleep, and disrupts functioning in all areas of life. Even as a behavioral health specialist, the relentless whine of tinnitus
had me trapped in a synergy of hurt.
For many years, predating my tinnitus, I have specialized in a science-based form of mental health treatment
called Cognitive Behavioral Therapy (CBT). CBT
is a set of learned skills—healthy habits and perspectives—that work together to change a person’s
emotional response to stress and trauma. In 2005,
at the height of my tinnitus distress, I used CBT to
help successfully manage my own condition.
What Causes Tinnitus Distress?
Thank your brain, for it errs on the side of keeping
you safe. Your brain is constantly on the alert for
potential danger. Any unexpected sensory stimulus—
a movement in your peripheral vision, a sudden noise,
the feeling of something crawling up your leg—can
With practice and patience, CBT can
help the patient habituate to tinnitus
and quiet the alarm in the brain.
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Tinnitus Today | Winter 2014
trigger your brain to react
against a possible threat.
This reaction is what scientists call hypervigilance.
Not surprisingly, your brain
judges tinnitus—a loud,
uncontrollable noise—as a
threat to your wellbeing,
and it puts your body on
alert. Tinnitus distress is
your brain sounding the
alarm about a perceived
possible danger.
Of course, many suspected threats turn out to be false
alarms. In most cases, the brain quickly learns that a
stimulus is not a threat. It then relaxes hypervigilance
and the sensory perception is gradually screened out
of awareness through a process called habituation.
Habituation explains why people routinely stop noticing loud, annoying noises after prolonged exposure.
A passing train, the roar of a freeway, air traffic, and
the hum of a refrigerator are common examples of
noises that eventually succumb to habituation.
For all its bluster, the sounds of tinnitus are a false
alarm—distracting and annoying, yes, but ultimately
harmless and unimportant. Research shows that the
majority of people with tinnitus do habituate and
are no longer bothered by the sounds. Until we can
silence tinnitus for good, ignoring tinnitus sounds
through habituation is a highly desirable end.
So, why do some people habituate to tinnitus and
others do not? Research indicates that it’s not the
tinnitus itself, but the person’s emotional response
to tinnitus that determines the course of habituation.
An emotional response that consists of resisting and
bracing against tinnitus maintains hypervigilance by
reinforcing the brain’s perception that tinnitus is an
imminent threat, an “intruder” that must be closely
monitored. Rather than learning to ignore tinnitus,
the persistently hypervigilant brain is locked into a
negative pattern that maintains emotional distress
and prevents habituation.
Careful Thinking: Getting a
New Perspective on Tinnitus
Our internal thoughts (cognitions) can
exert a strong influence over our feelings and actions. Personal judgments,
beliefs, and expectations can either
nurture healthy emotions and lifestyle,
or promote suffering, avoidance, and
withdrawal.
In my experience working with tinnitus patients—and even in my own
personal ordeal with tinnitus—I have
seen how negative thinking reinforces
hypervigilance, blocks habituation,
and impedes recovery. Common examples are “catastrophizing,” where the
patient jumps to the worst case scenario without considering other, more
likely outcomes, and “Mental Filter”
where the patient picks out a single
negative detail and dwells on it exclusively so that their vision of all reality
becomes darkened.
SCIENCE & RESEARCH
Cognitive Behavioral Therapy can
help break this pattern by changing
how the patient thinks and behaves in
response to tinnitus. With practice and
patience, CBT can help the patient
habituate to tinnitus and quiet the
alarm in the brain.
“The Breathing Space”
Here is a mindfulness exercise to help soften your inner relationship with tinnitus. The goal is to practice adopting a new
stance toward tinnitus, one that is open and accepting, that
allows tinnitus to exist as a strand in the fabric of your being.
Think of mindfulness as stepping back from a fire—you may
still feel the heat, but are no longer consumed by the flames.
The exercise takes about three minutes, though this may
vary as time and emotional stamina permit:
■
First, observe your experience by gently turning your
attention to sensations, then feelings, then thoughts, each
in turn. You may notice the sounds of tinnitus. For these
few minutes, practice allowing these sounds to be present, as part of your whole
experience, observing your
experience neutrally, in the
present moment, just letting
it unfold as it will.
■
Now turn your attention
to your breath, breathing
in a slow, relaxed manner.
Notice the rhythm of your
breath, the sensation of air
entering and exiting your
body, the slight increase
of tension as you inhale
and release as you exhale.
It is likely your attention
will wander—to tinnitus, to
thoughts about tinnitus, to
any other concern. Notice
these lapses as they occur
and gently, neutrally return
to your breath.
■
Finally, using your breath
as an “anchor”, return your
attention to your experience as a whole, gently
allowing tinnitus, any other sensations, thoughts and
feelings, to occur in the present moment, without
criticism and judgment.
CBT begins with a careful look at the
patient’s thoughts to identify cognitive
patterns that fan the flames of tinnitus
distress. The goal is to develop reasonable judgments and expectations
about tinnitus, a new perspective that
is grounded by facts, to provide reassurance and guidance throughout
recovery.
Acceptance and Mindfulness:
Learning to Share Your Space
with Tinnitus
The inner world of tinnitus distress is
characterized by resisting, fighting,
longing with every fiber of your being
for the sounds to stop. Such resistance
is understandable—tinnitus is genuinely stressful. But the fact remains that
there is no off switch for tinnitus. We
As you move back into your life, remember to bring this
calm, accepting attitude with you, returning often to your
breath to soften any distress.
(continued on page 14)
Winter 2014 | Tinnitus Today
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Cognitive Behavioral Therapy for Tinnitus
(continued from page 13)
have limited, or in most cases, no direct control over
the sounds and sensations. Until we find a cure,
wishing tinnitus will stop only feeds hypervigilance
and starves recovery. You can’t change tinnitus, but
you can change your inner relationship with the
sounds of tinnitus. Research suggests that acceptance—willingly sharing your space with tinnitus—
aids in recovery from tinnitus distress.
The benefits of acceptance are clear: You stop
banging your head against the tinnitus wall
and instead free up energy to go around it. You
relinquish attempts to control tinnitus in exchange for
the confidence of knowing you can handle it. You
come to find that tinnitus is not the boogey man you
have imagined. It is just a meaningless collection
of auditory signals that have no direct bearing on
the true value of your life.
Bruce Hubbard, Ph.D. is a Licensed Psychologist, an
Adjunct Assistant Professor at Columbia University
and Director of the Cognitive Health Group in
New York City. To learn more about Dr. Hubbard’s
experience with tinnitus and Cognitive Behavioral
Therapy, visit www.cbtfortinnitus.com.
Looking for a CBT Specialist?
Use ATA’s online Tinnitus Health
Professional Listing to find a
provider in your area.
Get started at www.ATA.org/provider-search
Sharing space with an intruder as invasive as tinnitus
is a courageous, noble endeavor. Studies show that
mindfulness can help. Mindfulness is the practice
of taking a more neutral, objective stance toward
tinnitus, to soften your emotional response, making
it easier to take the next step in your recovery.
Exposure: Rejoining Your Life
The most natural response to emotional distress is to
avoid experiences that trigger it. Disruptive in its own
right, tinnitus-induced avoidance can lead to more
serious conditions, like panic disorder, phobia, and
depression. The ultimate goal of CBT for tinnitus
is the return to a healthy lifestyle by resuming
the activities that bring happiness and meaning.
Exposure is the process of gradually reversing avoidance, reintroducing yourself to sound, to silence, and
to the activities you may have formerly believed to
be forever tarnished by tinnitus.
Exposure is a whole brain workout, enlisting each of
your new CBT skills—careful thinking, acceptance,
and mindfulness—to sand the edge off your distress
and make it easier to engage your new soundscape,
a new, valued life, even with tinnitus.
Recovery from tinnitus distress requires hard work,
persistence and time. My own experience with
tinnitus and CBT took many months and, admittedly, I had my own share of setbacks. But over time
I noticed the sounds of my tinnitus fading into the
background. Now I rarely notice my tinnitus, and
when I do, it is without the debilitating emotional
weight it once carried. Sweet habituation!
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Tinnitus Today | Winter 2014

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